SUMMARY (See instructions): The broad objective of the proposed research is to provide clinical comparative effectiveness evidence aimed at identifying the most effective approaches to post-fracture care with a focus on secondary fracture prevention. While there has been much interest in improving post-fracture bisphosphonate use, the incidence of second fracture is greatest early after the first fracturea time period in which pharmacological osteoporosis treatment will have little impact. We currently lack evidence regarding which post-fracture practices will reduce both short- and long-term secondary fracture incidence. We also lack evidence on interventions that might mitigate poor outcomes among the sub-group of elders who may not survive long enough to benefit from osteoporosis treatment. These knowledge gaps will be addressed by evaluating alternative post-fracture care strategies, encompassing the full spectrum of care delivery and medication use, across health systems and regions where differences in post-fracture care exist. By studying the large national population of fracture patients cared for in diverse settings (using Medicare claims data and Centers for Medicare & Medicaid Assessment files for inpatient rehabilitation, skilled nursing facilities, nursing homes and home health, all linked to Part D pharmaceutical data), we will be able to identify correlates of safe, effective post-fracture care. A multidisciplinary team expert in comparative effectiveness research will characterize the impact of variation in care patterns on secondary fracture, mortality, and health care costs. Aim 1 will address 6-month risk of secondary fracture considering rehabilitation characteristics and use of drugs that increase fall risk. Aim 2 will extend examination of secondary fracture incidence to 1 -year when access and adherence to osteoporosis treatment will become important. Aim 3 will study outcomes among those at high-risk for mortality (e.g. nursing homes residents). Aim 4 will use decision-analytic modeling to quantify the potential clinical and economic value of alternative interventions to improve post-fracture care. By evaluating the impact of alternative post-fracture care strategies in this proposal, the long-term health and economic consequences of specific interventions in post-fracture care can be more fully understood.